Other·May 13, 2026

Federal Regulations, Title 42, Section 483.12, Reporting of Alleged Violations (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Health and Safety Code, Division 2, Licensing Provisions, Chapter 2.4, Quality of long-Term Health Facilities, Section 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 4/12/26 at 8:05 a.m., an unannounced visit was conducted at the facility for the annual re-certification survey. The department determined the facility failed to ensure an alleged violation of abuse was reported immediately for two of 27 sampled patients (Patient 41 and Patient 52), when the Department did not receive a report of the alleged violation after the abuse incident's occurrence. This failure decreased the facility's potential to protect vulnerable patients and provide safe environment. A review of Patient 52's "Admission Record," indicated Patient 52 was admitted to the facility in December 2025 with a diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Patient 41's "Admission Record," indicated Patient 41 was admitted to the facility in March 2026 with diagnoses including difficulty in walking and generalized muscle weakness. A review of Patient 41's "Minimum Data Set (MDS- a federally mandated assessment tool)," dated 3/26/26, indicated Patient 41's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the patient) score was 15 out of 15 with good memory. During an interview on 4/12/26 at 9:13 a.m. with Patient 41, Patient 41 stated Patient 52 hit him with a wheelchair several times and attempted to punch him. A review of Patient 52's "Progress Notes," dated 3/7/26, documented by Licensed Nurse (LN) 4, indicated Patient 52 had an episode of verbal aggression towards roommate (Patient 41). Patient 52 was getting out of the room when he reversed the wheelchair and bumped into Patient 41's chair. Patient 52 became verbally aggressive towards Patient 41 when Patient 41 told him to stay away to avoid the accident. The notes further indicated Patient 52 tried to punch Patient 41. A review of Patient 41's "Census List," dated 4/15/26, indicated prior to 3/7/26 Patient 41 and Patient 52 were roommates and on 3/7/26 Patient 41 was moved to a different room. During an interview on 4/13/26 at 3:04 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated Patient 52 was upset and Patient 41 happened to be in the hallway. CNA 3 further stated Patient 52 was a "little aggressive" towards Patient 41. During an interview on 4/15/26 at 9:25 a.m. with LN 4, LN 4 stated she was passing medication when she heard Patient 52 talking very loud towards Patient 41 and stating, "get out of my way." LN 4 further stated Patient 52 tried to punch Patient 41. During a concurrent interview and record review on 4/13/26 at 3:37 p.m. with Director of Nursing (DON), Patient 52's progress note, dated 3/7/26, was reviewed. DON stated based on the progress note the incident was considered reportable. DON further stated the incident was not reported and should have been reported. During an interview on 4/15/26 at 11:42 a.m. with Administrator (ADM), ADM expected staff to report to him, as an abuse coordinator, any alleged abuse or suspected abuse. ADM stated alleged abuse, or suspected abuse should have been reported to officials within two hours. A review of the facility's policy titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised 9/2022, indicated, "If resident abuse ... is suspected, the suspicion must be reported immediately to the administrator and to other officials ... within two hours of an allegation involving abuse ..." Therefore, the department determined the facility failed to ensure an alleged violation of abuse was reported immediately for two of 27 sampled patients (Patient 41 and Patient 52), when the Department did not receive a report of the alleged violation after the abuse incident's occurrence. This violation had a direct or immediate relationship to the health, safety, or security of long-term care patients or residents.